Provider Demographics
NPI:1366705956
Name:FUGAJ, STEPHEN (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:FUGAJ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9207 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9782
Mailing Address - Country:US
Mailing Address - Phone:219-365-8696
Mailing Address - Fax:219-365-2121
Practice Address - Street 1:9207 WICKER AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-9782
Practice Address - Country:US
Practice Address - Phone:219-365-8696
Practice Address - Fax:219-365-2121
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011816A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist